TIME.com

Monday, January 20, 2003

As far as these patients are concerned, the problem is yours, not theirs

By Jeffrey Kluger

Posted Sunday, January 12, 2002; 8:31 a.m. EST
It has got so psychologist Lawrence Josephs can tell right away which patients are likely to fire him. The narcissists may be the worst. These are the ones who are there in the first place only because their spouse would not quit hectoring them to show more interest in the marriage, and the people at work just didn't seem to give them the credit or attention they deserve. Often, they stay only long enough to decide that what they really need is to leave the marriage and quit the job. After that, they sack the shrink.

"They come in under duress," says Josephs, a psychology professor at Adelphi University in Garden City, N.Y. "But they don't commit. What they really want is to have everything on their own terms."

If it's any comfort to Josephs, he's not alone in having such trouble managing narcissists—and it's not just the narcissists giving therapists such problems. Narcissism is one of 10 conditions under the diagnostic heading of personality disorders (PD), and by most accounts, narcissists are among psychology's toughest nuts to crack. Talk therapy often doesn't touch them; drug therapy may do just as little. Researchers know why.

Common mental conditions, such as anxiety disorders, eating disorders and depression, can be thought of as a pathological rind wrapped around an intact core. Peel the skin away through talk therapy or melt it away with drugs, and the problem may abate. Personality disorders, by contrast, are marbleized through the entire temperament. Narcissists may be self-absorbed, but they believe they jolly well have a right to be. Histrionic personalities may make too much of things, but how else can they be heard? It's hard enough to persuade most people to see a therapist—harder still when the patient denies there's a problem at all. "People rarely come in with a self-diagnosed personality disorder," says Josephs. "Friends and family push them into it."

These days they have more reason than ever to push. As families increasingly fragment and as societal pressures grow, experts say they are seeing more cases of personality disorder than ever. As much as 9% of the population is thought to suffer from some kind of personality disorder, and as many as 20% of all mental-health hospitalizations may be the result of such conditions.

Epidemiologists have not done a very good job of comparing these figures with those of earlier years, but many doctors report—anecdotally—that their PD caseload is indeed on the rise. "The more severe ones are increasing," says Josephs, "especially among people who grew up in homes with divorce or drug and alcohol problems."

As this happens, more and more researchers are looking for new ways to treat the conditions—exploring both genetic and environmental roots, seeking both therapeutic and chemical cures. And well they might. "The social costs of personality disorders are huge," says Dr. John Gunderson, director of the Personality Disorders Service at McLean Hospital in Belmont, Mass. "These people are involved in so many of society's ills—divorce, child abuse, violence. The problem is tremendous."

While solutions are elusive, the pathological arc of PDs is predictable. They tend to show up after age 18, striking men and women equally—though gender may influence which of the 10 disorders a person develops. The disorders are grouped into three subcategories, and of these, the so-called dramatic cluster—borderline, antisocial, narcissistic and histrionic disorders— is the best known. But it's the borderlines who cause doctors—to say nothing of families—the most headaches.

People with borderline-personality disorder form exceedingly volatile relationships, whipsawing between idealizing family and friends and dismissing them as worthless or hateful. They are intensely afraid of being abandoned but react so savagely when a loved one disappoints them that abandonment is often just what they get. Prod these people into therapy, and the same dynamic unfolds there. "At one point, you're their closest friend, and two weeks later, you're the enemy," says Norman Clemens, a psychology professor at Case Western Reserve University in Cleveland.

Histrionic and narcissistic personalities use drama or self-absorption in much the same way—pushing away family and exasperating therapists. People with antisocial personalities raise the stakes higher, exhibiting aggressiveness, lack of conscience and indifference to the law, often folding criminal behavior into their pathology.